INTRODUCTION

It has been five years since we responded to a call for action to improve the health of Oklahomans through development of the Oklahoma Health Improvement Plan. Since we issued the report in 2010, we have seen major gains in critical health outcomes. Some examples include:

Reduction in the percent of public high school students who are obese

Reduction in the infant mortality rate

Increase in the number of school districts working to create a healthy environment that incorporates nutritious food and time for physical activity

Reduction in tobacco use among adults and adolescents

Increase in the number of schools that are tobacco free 24 hours a day, 7 days a week

Yet, there is still room for improvement. Many Oklahomans continue to be obese. A large percentage of pregnant women do not receive prenatal care and many babies are born with low birth weight, especially among African-American people. Too many youth begin smoking or using tobacco products every year. Some Oklahomans don’t have the same access to quality health services as others. We must create and assure conditions where the healthy choice is the easy choice to address the health challenges we face in our state and meet the goals of Healthy Oklahoma 2020.

This plan focuses our efforts on making improvements in key strategic areas and creating a culture of health. Making improvements in these flagship issues will have the greatest impact on the health of Oklahomans now and for future generations.

TOBACCO USE

The OHIP acknowledges the traditional and sacred use of tobacco among American Indian people living in Oklahoma. Whenever the word tobacco is referenced in this report it refers to the use of commercial tobacco.

Tobacco continues to be the leading preventable cause of death in Oklahoma, causing about 6,000 deaths in our state per year. Smoking kills more Oklahomans than alcohol, auto accidents, AIDS, suicides, murders and illegal drugs combined. 31

Oklahomans spend approximately $1.62 billion per year on smoking-related health costs, while the tobacco industry spends an estimated $160.3 million dollars annually to market tobacco products in Oklahoma. 32, 33, 34

The Oklahoma adult smoking prevalence decreased from 26.1% in 2011 to 23.3% in 2012 and remained steady at 23.7% in 2013.2 Oklahoma’s adult smoking rate is still far above the national average of 17.8%. 35

Approximately one in four Oklahoma adults smoke compared to one in five nationally.2 The percentage of public high school students who were current, frequent smokers decreased from 9.1% in 2009 to 5.5% in 2013.5 Each year about 4,400 Oklahoma children become new daily smokers. 36

OHIP measures focus on 1) decreasing the incidence of chronic disease caused by or impacted by tobacco use and secondhand smoke exposure and 2) decreasing the proportion of Oklahoma children who become new daily smokers.

CORE MEASURES

Reduce adolescent smoking prevalence from 15.1% in 2013 to 10% in 2020 for high school-aged youth and from 4.8% in 2013 to 2% in 2020 for middle school-aged youth (2018 data).

OBESITY

Oklahoma’s adult obesity rate at 32.5% puts Oklahoma at the 7th highest adult obesity rate in the nation. 2,37 Disparities exist wherein obesity rates remain higher among black and Latino communities than among whites. National findings reveal that significant geographic, income, racial and ethnic disparities persist, with similar disparities found in Oklahoma.

The factors leading to obesity are complex. Public health approaches that affect large numbers of different populations in multiple settings—communities, schools, worksites and healthcare facilities—are needed. Policy and environmental initiatives that create incentives to make healthy nutrition choices and physical activity opportunities available will prove most effective in combating obesity. 38

CORE MEASURES

CHILDREN’S HEALTH

The health and well-being of mothers, infants, children and adolescents are fundamental to our state’s future. Of great concern, Oklahoma ranks poorly for many key indicators of maternal and child health which will have long-term consequences for our state’s health going forward if improvement for this population is not realized. The Children’s Health portion of the OHIP addresses key life course stages – maternal and infant health, child and adolescent health – with goals, objectives and performance measures for each.

According to the Bureau of Health Resources and Services Administration (HRSA), the life course approach to conceptualizing healthcare needs and services evolved from research documenting the important role early life events play in shaping an individual’s health trajectory.

When examined through the context of a life course model, the work of this particular flagship issue can be summarized by timeline, timing, environment and equity.

Today’s experiences and exposures influence tomorrow’s health (timeline), the path of one’s health is particularly affected during critical or sensitive periods (timing), the broader community environment strongly affects the capacity to be healthy (environment) and inequality in health reflects more than genetics and personal choice (equity). If, as a state, we take advantage of these life course opportunities – we will greatly accelerate improvement in our overall health as the next generation arrives equipped to live, work and lead this state with vitality and purpose.

In order to achieve further improvement in birth outcomes, women must practice healthy behaviors and be engaged in primary and preventive healthcare services throughout their reproductive lives, including the time before they become pregnant (preconception) and between pregnancies (inter-conception). Making health a priority for children and adolescents ensures the health of future generations.

During this time of physical and mental growth, children and adolescents can learn to build a strong foundation for healthy behavior. Research has shown that many medical conditions affecting adults have roots in childhood.

CORE MEASURES

Reduce infant mortality from 6.8 per 1,000 live births in 2013 to 6.4 per 1,000 live births by 2020 (2018 data).

Reduce Maternal Mortality from 29.1 per 100,000 live births to 26.2 per 100,000 live births by 2020 (2018 data).

Reduce Infant, Child and Adolescent Injury Mortality from 15.2 per 100,000 in 2013 to 13.9 per 100,000 by 2020 (2018 data).

BEHAVIORAL HEALTH

Mental health and substance abuse issues are among the most pressing concerns facing our state today. In the past year, 21.9% of adult Oklahomans reported having a mental health issue and 12% experienced a substance abuse issue40 representing 700,000 to 950,000 Oklahomans living with diseases of the brain.

Oklahoma consistently ranks among the highest in the region, and nationally, for rates of mental illness and addiction, as well as prescription drug abuse, underage drinking and suicide. Oklahoma ranks 49th nationally for mental illness among adults,40 11th worst for suicide at 17.6 per 100,000 people (670 deaths),41 45th at 19.8 per 100,000 people for drug overdose deaths42 and is tied at 44th in its ranking for the number of “poor mental health days.” 8

Ties to other chronic health issues are also well documented. According to the Medical Expenditure Panel Survey (MEPS) data from 2003, mental disorders are the third leading chronic disease in the nation – behind only cancer and heart disease.

The projection of growth percentage in the number of people reporting mental disorders between 2003 to 2023 is 53.8%, which will be more prevalent than heart disease (projected at 41%), diabetes (projected at 53%), and stroke (projected at 29%).42 Life expectancy for people with untreated behavioral health diseases is significantly less than the general population, upwards of 25 – 30 years.43

Dedicated attention to diseases of the brain is critical to improving the health of our state.

CORE MEASURES

Reduce the prevalence of untreated mental illness from an 86% treatment gap to 76% in 2020 (2018 data).

Reduce the prevalence of addiction disorders from 8.8% to 7.8% by 2020 (2018 data).

Reduce suicide deaths from 22.8 per 100,000 in 2013 to 19.4 per 100,000 by 2020 (2017 data).

SOCIAL DETERMINANTS

Demographics

From 2010 to 2013, the Oklahoma estimated total population has grown from 3,761,702 to 3,850,568 people (2.4%). In 2013, 79.9% of the population were white; 13.3% American Indian; 8.9% were African-American; 3.1% was some other race; 2.4% were Asian; and 0.3% was Native Hawaiian and other Pacific Islander. The estimated percentage of whites has declined 0.6%. American Indians/Alaska Natives have increased 3.2%, while African-Americans and Asian populations remain fairly constant. During this same time period, the Hispanic population has grown 0.8%.11 In 2013, 35.0% of Oklahomans live in rural communities.12 The population in rural Oklahoma has steadily declined since the middle of the last century and most of the population growth is concentrated around the metropolitan areas and expanding suburban communities.13

Education

In 2013, 86.7% of Oklahomans 25 years and older have a high school degree or higher and 23.5% have attended college but obtained no degree. Only 16.1% of Oklahomans have a bachelor’s degree and 7.7% have a graduate or professional degree. Less than half of Oklahomans over 25 years of age (45.6%) have no college experience.11

Poverty and Income

In 2013, as many as 16.8% of Oklahomans earned income in the past 12 months that is below poverty level, compared to the national average of 15.8%. The child poverty rate for Oklahoman children under 18 is 24.0%. While Oklahoma’s unemployment rate is better than the national figure, the state’s median household income of $45,690 is 14.6% lower than the national figures.11

Access to Healthcare

The rate of uninsured Oklahoman adults dropped from 18.4% in 2012 to 17.7% in 2013; nevertheless it was still 5.0% higher than the national rate.14 One in four Oklahoma adults (35th in the nation) reported they did not have a usual source of care.9 In 2014, Oklahoma only has 84.8 primary care physicians per 100,000 populations (48th in the nation).8 The need is greater in rural Oklahoma where 40% of the population is served by only 28% of the 3,660 primary care physicians in Oklahoma.15 The physician workforce is aging; furthermore, primary care physicians in rural Oklahoma are older compared to their urban counterparts.16

Access to Food and Food Insecurity

In 2012, it is estimated that 17.2% (656,300) of Oklahomans experience lack of access to enough food for all household members and uncertain availability of nutritiously adequate foods, including nearly 239,380 children.17 Out of the 77 counties in Oklahoma, residents in 43 counties have to travel more than 10 miles to reach a full service grocery store in rural areas and more than a mile to a grocery store in urban areas.18

Housing

The percentage of Oklahomans paying home mortgages that are 30% or more of their income is 24.4%. Approximately 18% of Oklahomans are paying 35% or more of their income. Approximately 45% of Oklahomans are paying rent at or above 30% of their income and 36.3% pay rent at 35% or more of their income.11

Aging

In 2014, Oklahoma was ranked 47th in the health of older adults, an improvement from a 49th ranking in 2013.19 Significant challenges for the health of older adults in Oklahoma include the highest rate of hip fractures among Medicare beneficiaries, the second highest rate of physical inactivity, the third highest rate of falls, the seventh highest ranking overall on unhealthy behaviors, and the lowest rate of hospitalized older adults who received recommended care for heart attack, heart failure, pneumonia, and surgical procedures. Oklahoma ranked the last overall in public health policies and programs supporting older adults.19 Older adults are currently 14.2% of Oklahoma’s population and their numbers are projected to increase by 36.8% from 2015 to 2030.11,19

Disability

Approximately 15.8% of Oklahomans living at home have a disability.11 Nearly 9 out of 10 Oklahoma adults have difficulty using everyday information that is routinely available in healthcare facilities, retail outlets, media, and communities.20

Personal Health Behaviors and Health Outcomes

Many Oklahomans engage in lifestyles and behaviors that put them at a higher risk for chronic diseases, disabilities, and deaths. These behaviors are directly related to the leading causes of death in Oklahoma, including cardiovascular disease, cancer, stroke, respiratory disease, and unintentional injuries.

HEALTH TRANSFORMATION

The Commonwealth Fund ranks Oklahoma’s state health system performance 49th among the 50 states and Washington D.C. 44 Oklahoma has several initiatives underway that aim to transform the health system into one that bends the healthcare cost curve, increases healthcare quality, and improves population health outcomes (the Triple Aim).

In order to accomplish this, Oklahoma will need to implement innovative and evidence-based strategies that accelerate and reinforce the healthcare triple aim and transform Oklahoma’s current health system into a more sustainable and value-based model.

This includes initiatives that prevent disease at the earliest stage possible, providing care coordination to individuals with chronic conditions (both physical and behavioral) in order to reduce significant health consequences and excessive healthcare utilization, payment strategies that reward health providers and systems for achieving population health improvement and better integrating healthcare systems with community level health improvement initiatives.

Recent efforts to address Oklahoma’s health system

transformation have resulted in the identification of four core areas of work:

CORE MEASURES

Improve Quality of Care – Reduce by 20% the rate, per 100,000 Oklahomans, of potentially preventable hospitalizations from 1656 in 2013 to 1324.8 by 2020 (2019 data).

Bend the Healthcare Cost Curve – By 2020, limit annual state-purchased healthcare cost growth, through both the Medicaid Pro- gram and the State Employee Group Insurance Plan (EGID), to 2% less than the projected national health expenditures average annual percentage growth rate as set by CMS (estimated baseline for annual state-purchased healthcare cost growth = 5.11%).

CALL TO ACTION

The Oklahoma Health Improvement Plan is designed to inspire an entire state to work collaboratively together to help Oklahomans live healthier, happier, and longer lives. While great strides have been made in recent years, more work is needed as many Oklahomans are dying unnecessarily and prematurely. Integrating the input and findings derived from published health data, stakeholder and community engagement, and evidence-based frameworks and practices, the 2015-2019 OHIP proposes new ways of interacting, new structures for communication, and a renewed hope that progress on issues of mutual interest can be achieved through private-public and tribal partnerships as well as individual Oklahomans’ commitment and involvement.

ALL OKLAHOMANS ARE ASKED TO DO THEIR PART AND PARTICIPATE IN CREATING A CULTURE OF HEALTH THROUGH THE FOLLOWING ACTIONS:

21. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2013. Retrieved from http://apps.nccd.cdc.gov/brfss/

25. World Health Organization, Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. CSDH final report. Geneva: World Health Organization

29. U.S. Department of Health and Human Services, Health Resources and Services Administration. (November 2010). Rethinking MCH: The Life Course model as an organizing framework. Atlanta: U.S. Department of Health and Human Services. Retrieved from http://mchb.hrsa.gov/lifecourse/rethinkingmchlifecourse.pdf

36. New underage daily smoker estimate based on data from U.S. Dept of Health and Human Services (HHS), “Results from the 2010 National Survey on Drug Use and Health, with the state share of national initiation number based on CDC data on future youth smokers in each state compared to national total.